2016 Healthcare Provider Orientation Flight

Please consider my nomination:

Date - July 14, 2016

Time - 8:00 a.m. - 3:00 p.m.

Location - Rickenbacker National Guard Base

7370 Minuteman Way

Columbus, Ohio 43217

Question Title

* Nominee:

Title

First Name

Last Name

Organization

Position/Specialty

Street

City

Zip Code

Email Address

Cell Phone

Question Title

* Do you care for TRICARE beneficiaries?

Question Title

* Nominated by (self nominations are encouraged):

Title/Rank

First Name

Last Name

Organization/Unit

Cell Phone

Question Title

* Gender

Question Title

* Are you a racial or ethnic minority?

Please submit nominations by March 1, 2016

For additional information, please contact the Ohio National Guard Community Outreach Office at 614-336-7002 or Kathryn.L.Lowrey.mil@mail.mil

Please understand that being nominated does not necessarily guarantee selection and that this experience is a once in a lifetime opportunity. If you have participated in the past, please allow others to participate. Nominees will be asked to complete a flying medical screening form. Unfortunately, we are unable to accommodate persons with physical limitations that could interfere with your ability to make an unlikely emergency exit from the aircraft and other medical conditions may be disqualifying.